Archives of Women's Mental Health

, 14:435

Bio-socio-demographic factors associated with post-traumatic stress disorder in a sample of postpartum Brazilian women

Authors

    • Psychiatric of Neuropsychiatry DepartmentAffective Disorders Unit, Federal University of Pernambuco
  • Amaury Cantilino
    • Psychiatric of Neuropsychiatry DepartmentAffective Disorders Unit, Federal University of Pernambuco
  • Everton Botelho Sougey
    • Psychiatric of Neuropsychiatry DepartmentAffective Disorders Unit, Federal University of Pernambuco
Short Communication

DOI: 10.1007/s00737-011-0224-4

Cite this article as:
Zambaldi, C.F., Cantilino, A. & Sougey, E.B. Arch Womens Ment Health (2011) 14: 435. doi:10.1007/s00737-011-0224-4

Abstract

Post-traumatic stress disorder (PTSD) is common among women. In the postpartum period, the prevalence is between 1% and 6%. The present study investigated PTSD in a sample of 400 Brazilian women between 2 and 26 weeks postpartum using the Mini-International Neuropsychiatric Interview and found a frequency of 5.3%. The factors associated with the occurrence of PTSD were low purchasing power, a history of psychiatric disorders, clinical disease, and the infant having experienced some complication

Keywords

PostpartumPuerperiumStressPost-traumatic stress disorder

Introduction

Post-traumatic stress disorder (PTSD) is more likely to develop in females than in males following exposure to a traumatic event (Breslau et al. 1997, 1998, 1997; Tolin and Foa 2006). Research consistently finds that men are more likely to experience traumatic events (Kessler et al. 1995; Stein et al. 1997), whereas women are more than twice as likely to develop PTSD (Wolfe and Kimerling 1997; Norris et al. 2002; Tolin and Foa 2006; Breslau et al. 1997). However, the types of trauma men and women experience are not equivalent. Women are more likely to report sexual assault, whereas men are more likely to report gunshot wounds, physical assaults, motor vehicle accidents, and combat (Breslau et al. 1998; Kessler et al. 1995; Stein et al. 1997). Explanations for gender differences regarding the PTSD rate may involve individual characteristics and the type of traumatic experience (Breslau et al. 1997; Tolin and Foa 2006).

The current estimated prevalence of PTSD is 2% for women and 1% for men (Stein et al. 1997; Pergonigg et al. 2001). Few studies have examined the prevalence and nature of postpartum PTSD or other anxiety disorders in this period (Wenzel et al. 2005). The existing literature on postpartum PTSD typically focuses on traumatic childbirth (Bailhan and Joseph 2003; Beck 2004; Czarnocka and Slade 2000; Reynolds 1997; Wijma et al. 1997). Using childbirth as the index stressor, the prevalence rate of PTSD is between 1.3% and 5.9% (Zambaldi et al. 2010).

PTSD during the postpartum period can have a negative impact on the mother–infant interaction. Studies of interactions between anxious mothers and their children report that such women exhibit less sensitive responsiveness and reduced emotional tone during interactions with their babies (Nicol-Haper et al. 2007) and are less warm and less positive (Whaley et al. 1999). A qualitative study involving mothers with PTSD related to traumatic childbirth found reports of rejection of the infant, along with either avoidant or overprotective behavior towards the child (Ayers et al. 2006).

There are few studies of postpartum anxiety disorders in Brazil. No study was found in indexed periodicals on PTSD in Latin American women. The aim of the present study was thus to investigate the prevalence of postpartum PTSD related to childbirth as well as other types of trauma and identify the associated risk factors. This article hopes to contribute to the body of knowledge regarding this disease in postpartum women.

Method

This study was approved by the ethics committee of the Fernando Figueira Maternity-Children’s Institute (Brazil). All participants signed the terms of informed consent.

A convenience sample of 400 new mothers was recruited from three medical institutions during routine pediatric evaluations of their newborns: 294 from two public hospitals (the Hospital of the Federal University of Pernambuco and Fernando Figueira Maternity-Children’s Institute) and 106 from a private office, all located in the city of Recife, in the Brazilian state of Pernambuco. The aim of this procedure was to obtain a representative population comprising subjects from different socioeconomic backgrounds.

The inclusion criteria were as follows: (1) ability to speak, read, and understand Portuguese; (2) between 2 and 26 weeks postpartum; (3) delivery of a live, healthy infant that was alive at the time of the interview; and (4) willingness to participate in the study.

The Mini-International Neuropsychiatric Interview (MINI) (Soderquist et al. 2009), in its Portuguese version (Stein et al. 1997), was used to diagnose current PTSD and determine whether the disorder started after or before the delivery. A questionnaire on socio-demographic characteristics was used to ascertain the following information: (a) general demographic background; (b) data relating to the course of the pregnancy, delivery, and postpartum events; (c) personal and family psychiatric history; and (d) socio-professional status. Treatment was offered for all women diagnosed with PTSD.

The level of significance was set at p < 0.05 (two-tailed test). Statistical analysis was performed using the SPSS program, version 13.

Results

The mean age of the sample (n = 400) was 27.2 years ± 6.05 (range 15–44 years). Three hundred and forty-two (85.5%) were married or lived with a partner, 138 (34.5%) had an unplanned pregnancy, and 141 (35.30%) experienced some kind of complication during pregnancy or on delivery. Two hundred women from the sample (50%) were unemployed, 141 (35.3%) had low purchasing power (family income of one minimum wage or less), and 155 (38.8%) had moderate purchasing power (family income of between two and five minimum wages).

Twenty-one (5.3%) met the diagnostic criteria (MINI) for PTSD, eight of whom (2.3%) reported postpartum onset of the disorder. In the 21 women with PTSD, there were cases of traumatic childbirth, but also childhood trauma, assault, and sexual violence. There were cases of sexual assault, partner violence, crime, seeing others injured or killed, and death of a loved one. The women with postpartum onset of PTSD reported traumatic birth and partner violence during pregnancy.

Table 1 displays the socio-demographic characteristics, obstetric history, complications in the infant, and history of somatic disease or psychiatric disorders among the women with (n = 21) and without (n = 379) PTSD. PTSD was more frequent among postpartum women with low purchasing power, with a personal history of previous psychiatric disorders or somatic disease and those whose infant experienced some medical complication. The most common somatic diseases were arterial hypertension and diabetes mellitus and the most common complications with the baby were prematurity, low birth weight, and jaundice. It was not possible to identify specific previous psychiatric disorders. There were no significant differences between postpartum women with and without PTSD in terms of marital status, level of education, employment status, unwanted pregnancy, obstetric complications during pregnancy or on delivery, method of delivery, low birth weight, need for hospital care of infant, or family history of psychiatric disorders.
Table 1

Socio-demographic characteristics, obstetric history, and history of somatic disease or psychiatric disorder

Variable

Total sample (n = 400) (%)

Postpartum women with PTSD (n = 21) (%)

Postpartum women without PTSD (n = 379) (%)

p value*

OR (CI 95%)

Marital status

p = 0.543b

 

Married/live with the partner

342 (85.5)

17 (80.9)

325 (85.8)

Single/divorced/widowed

58 (13.5)

4 (19.1)

54 (14.2)

1.4 (0.46–4.37)

Professional status

p = 0.070b

 

Employed

198 (49.5)

6 (28.6)

192 (50.6)

Unemployed

200 (50.0)

14 (66.7)

186 (49.1)

1.42 (0.16–1.10)

Missing data

2 (0.5%)

1 (4.7)

1 (0.3)

Level of education (years)

p = 0.072b

 

0–8

42 (10.5)

4 (19.0)

38 (10.0)

 

9–11

92 (23.0)

7 (33.4)

85 (22.4)

a

12–17

186 (46.5)

10 (47.6)

176 (46.5)

≥18

80 (20)

0

80 (21.1)

Purchasing power

p = 0.005*, b

 

Low

141 (35.3)

14 (28.6)

127 (33.5)

  

 Intermediate

155 (38.7)

6 (66.7)

149 (39.3)

 

a

High

104 (26.0)

1 (4.7)

103 (27.2)

 

Pregnancy

p = 0.319b

 

Unwished

260 (65.0)

11 (52.4)

249 (65.7)

Wished

138 (34.5)

9 (42.9)

129 (34.0)

0.63 (0.26–1.57)

Missing data

2 (0.5)

1 (4.7)

1 (0.3)

Obstetric complications in pregnancy or at birth

p = 0.093b

 

Yes

141 (35.25)

11 (52.4)

130 (34.3)

2.1(0.87–5.07)

No

258 (64.5)

10 (47.6)

248 (65.4)

Missing data

1 (0.25)

1 (0.3)

Method of delivery

p = 0.441b

 

Vaginal birth

157 (39.25)

11 (52.4)

146 (38.5)

Cesarean section

242 (60.5)

10 (47.6)

232 (61.2)

a

Missing data

1 (0.25)

1 (0.3)

Weight of the baby

p = 0.520c

 

≥2.500 Kg

328 (82.0)

18 (85.7)

310 (81.8)

0.82 (0.24–2.87)

<2.500 Kg

66 (16.5)

3 (14.3)

63 (16.6)

Missing data

6 (1.5)

6 (1.6)

Pediatric complications with the baby

p = 0.042*

 

Yes

97 (24.3)

9 (42.9)

88 (23.2)

2.47 (1.01–6.06)

No

302 (75.5)

12 (57.1)

290 (76.5)

Missing data

1 (0.3)

1 (0.3)

Baby stay in hospital

p = 0.453b

 

Yes

105 (26.2)

7 (33.3)

98 (25.8)

1.43 (0.56–3.64)

No

294 (73.5)

14 (66.7)

280 (73.9)

Missing data

1 (0.3)

1 (0.3)

Women with some somatic disease

p = 0.024*, b

 

Yes

53 (13.2)

6 (28.6)

47 (12.4)

3.00 (1.11–8.24)

No

345 (86.3)

14 (66.6)

331 (87.3)

Missing data

2 (0.5)

1 (4.8)

1 (0.3)

Personal history of psychiatric disorder

p = 0.002*, b

 

Yes

37 (9.2)

6 (28.6)

31 (8.2)

4.47 (1.62–12.33)

No

361 (90.3)

15 (71.4)

346 (91.3)

Missing data

2 (0.5)

2 (0.5)

Family history of psychiatric disorder

p = 0.002*, c

 

Yes

113 (28.25)

9 (42.9)

104 (27.4)

1.947 (0.79–4.76)

No

282 (70.5)

12 (57.1)

270 (71.3)

Missing data

5 (1.25)

5 (1.3)

PTSD post-traumatic stress disorder

*p < 0.05, statistically significant

aOR are not computed because either (1) the group variable does not have exactly two distinct non-missing values or/and (2) the response variable does not have exactly distinct non-missing values

bValues based on Pearson chi square

cValues based on Fisher’s exact test

Discussion

Although this study covered the types of trauma other than childbirth and included women with previous PTSD, the prevalence of PTSD found (5.3%) was similar to that described in other studies of PTSD following traumatic childbirth (Bailhan and Joseph 2003; Beck 2004; Czarnocka and Slade 2000; Reynolds 1997; Wijma et al. 1997). Women with prior history of psychiatric disorders appear to be the group that is most vulnerable to PTSD (Wijma et al. 1997; Czarnocka and Slade 2000). In the present study, PTSD was four times more prevalent among the women with a history of some psychiatric disorder. Another risk factor observed was somatic disease, low purchasing power, and complications in the baby.

Previous trauma, personality characteristics such as depression, high anxiety, low ability to cope with stress, and low perceived social support have also been associated with the occurrence of PTSD but these factors were not investigated in this study (Soderquist et al. 2009). As in previous studies, no significant associations were found between PTSD and marital status (Wijma et al. 1997; Adewuya et al. 2006; Soderquist et al. 2009), schooling (Wijma et al. 1997; Adewuya et al. 2006; Soderquist et al. 2009), employment status, or unwanted pregnancy. Experiencing obstetric complications during pregnancy or childbirth and undergoing a cesarean section have often been associated with PTSD (Maggioni et al. 2006), but no such associations were found in the present study.

This study has a number of limitations that should be mentioned. There was no investigation of other risk factors such as peripartum dissociation, presence of partner during childbirth, satisfaction with the health care team, and previous traumatic events. Moreover, the types of traumatic events experienced were not recorded quantitatively.

Conclusion

Little data is available on PTSD in postpartum Latin American women. The findings of the present study suggest that this disorder is frequent and merits more attention from physicians and researchers. The women most susceptible to PTSD are those with a history of psychiatric disorders, those with a clinical disease, low purchasing power, and those whose infant has experienced complications during or following birth.

Copyright information

© Springer-Verlag 2011